Self-medication: the basics for HSTS

The UK is suffering a backlash against transition and HSTS are affected disproportionately. This assault is being orchestrated by TERFs, so called ‘gender-crits’ and justifies itself using the words of individuals like Oren Amitay and Ken Zucker, while conspicuously ignoring the advice of those like Dr Diane Ehrensaft. As a result, a number of worrying developments have taken place recently which may lead to young trans people not being able to access the hormones and treatments they need. Self-medication, while not ideal, must be considered.

We note also, with concern, that various Government bodies in the UK have been deleting links to advice sites on transsexualism, for example Mermaids. We’ll be putting up these links up here so that people can access them.

Many thanks to Transit UK for their information.

https://transit.org.uk/hrt-internet.html

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In the world today there are an estimated 50 million or so trans women. The vast majority of these women are practising some form of self-medication.  Across southeast Asia, in Latin America and elsewhere, it is normal for such girls to begin self-medication around the age of 12. That is one reason why they grow up into such beautiful women. Very few have any health issues associated with their HRT and most are using some form of contraceptive pill. This is not ideal, but it is certainly effective.

Venus Flytrap – an all trans woman pop act from Thailand. They began their transition via self medication. It apparently worked.

If you’re a young person in the UK, with gender dysphoria, you may have to consider self-medication if possible, ideally using full cross-hormones. This is because the services available in the UK, through the National Health Service, are limited and already overstretched, with waiting times of up to three years for even a first appointment. This is an outrageous delay that compromises young people’s well-being and leaves them little choice other than self-medication.

However the approaches to medication are not the same for boys and girls and there are several forms of gender dysphoria. Unfortunately an entirely specious ‘balance fallacy’ has grown up, which proposes that there must be a female equivalent for every male condition and vice versa, and perhaps even worse, that all forms of gender dysphoria are the same. This is not true.

Genuinely pretranssexual boys and girls, sometimes called ‘transkids’ will have shown ‘persistent, insistent and consistent’ cross-sex identification from early childhood, perhaps as early as age 30 months and this is nearly always established by 54 months. In all areas they will be typical of the opposite sex rather than their own, and this is not a passing phase. They will become increasing resistant to attempts to ‘re-gender’ or ‘normalise’ their behaviour as they grow up. Further, they will invariably crush on the same sex and as they pass into puberty, their erotic attachments will follow this. In short, their aetiology is identical to that of a cis-girl (if male) or a cis-boy (if female). These are Sexual Inverts and if they transition will be HSTS.

If trans identification persists through puberty, that is, Tanner Stage 2, then the situation for boys and girls becomes different. That is because the changes brought about by testosterone are irreversible and much more obvious than those brought about by oestrogen.  In addition, it is significantly easier for a young cis-woman to operate as a butch lesbian than it is for a young male to operate as a woman. Feminine boys are likely to suffer physical and mental abuse and exclusion and will be unable, in the West, to avail the partners they desire, straight men.

Note that Inverted boys do NOT desire ‘gay men’ and girls do not desire other butch lesbians. The former seek to partner conventional heterosexual men, as women, and the latter seek conventional heterosexual women, to whom they will play a male social and sexual role. Men are  repulsed by masculinity in their partners and so a male Invert, in order to succeed, must totally suppress any that she has, in order to ‘pass’. Therefore, boys in this group need to consider arresting puberty as soon as possible, while girls can reasonably wait longer.

The approach advocated by the World Professional Association for Transgender Health (WPATH) which is reasonable for boys, suggests using anti-androgens to block testosterone production or to prevent it having its normal effect. WPATH suggests using anti-androgens only for a period of time, followed by oestrogen. However, sex hormones are necessary in proper bone development and other areas, so we believe that replacement oestrogen should be given at the same time. The ideal should be to closely approximate the hormone levels in a normal female of the same age.

For Sexually Inverted females who are correctly identified, a similar approach may be reasonable.

Unfortunately, many of those who transition are not Inverts and have some other form of Gender Dysphoria. This also applies in males but since the treatment for Female-to-Masculine therapy is much more drastic in its effects than Male-to Feminine, caution is indicated. This is especially so in the case of non-homosexual gender dysphorias, where significant levels of regret exist.

In females, the most common form of non-homosexual gender dysphoria today is called Rapid Onset Gender Dysphoria or ROGD. There have been a number of opinions expressed about this, including that of Dr Ray Blanchard, who believes it may be connected to what he calls ‘Autohomoeroticism’ or AHE, which is the desire, on the part of a female, to relate to others as a homosexual man. This phenomenon did not occur in any statistically significant numbers prior to 2010, if it did at all, and it is our opinion that NO HORMONAL OR SURGICAL intervention should be applied to females in this group prior to age 18. The regret and desistance rates within this group are already far elevated over others.

One other gender dysphoria, which only occurs in males, is a non-homosexual form that is called, in the Diagnostic and Statistical Manual (DSM) ‘Adolescent ir Adult onset’ or ‘Late Onset’. In Blanchard theory this is caused by a paraphilic condition called Autogynephilia (AGP).  This may set on as young as nine and may ‘telegraph’ even earlier, but in the main it establishes itself around Tanner Stage 4, age fifteen up.

This presents a serious dilemma for both the subjects and their parents, because young males in this group are not naturally feminine in the way that Inverts (HSTS) are and so they are even more likely to be compromised, in their desire to live undetected as women, than Inverts. Early arrestation of testosterone in these cases becomes more desirable, but due to the somewhat later average age of appearance, this presents fewer ethical problems. Nearly all males in this group will begin HRT around 18 or later and may be treated as adults.

HRT Online

Thankfully, it is still possible to buy HRT online and self-medication is legal in most countries. This page attempts to provide safe instructions for purchasing and administering HRT without a prescription. it includes information on blood tests and endocrinology.

When a transgender or trans person wishes to begin taking hormones, they may run into some problems (gatekeeping doctors, long waiting times, and so on). This can cause some distress, for some people. If you are one of them, and you satisfy the criteria in the first part of this essay, then self-medication can be a good alternative. Note that if you are a female with ANY form of ROGD then you should ONLY transition socially. No self-medication in these cases.

What to do

You may ask your parents to take you to see GenderGP, a private gender clinic, which is on this list of private trans clinics. Their waiting times are low, while NHS waiting times are literally years, and you will go through your full natal puberty if you’re left waiting for NHS treatment. Particularly for those born male, this is a serious issue as masculinisation must be arrested as early as possible.

Otherwise, especially if you’re an adult, we recommend private treatment if you can afford it, instead of self-medication. Your waiting times will be considerably reduced. You should also get yourself immediately on the waiting list to see someone at an NHS gender clinic. This will not cause problems with using private services or self-medication for the meantime.

 

Outside the UK.

Mexico

HRT is over the counter in Mexico. Inexpensive options include for pills Mileva-35 (same composition as Diane-35), Diane-35 and for injections Patector.

Portugal

In Portugal, it is possible to purchase estradiol over the counter at some pharmacies. Look around. We’re not sure exactly what brand or type, but this can be a legitimate way to get estradiol without a prescription in Portugal.

Spironolactone is not available OTC in Portugal. You have to get it prescribed or buy it on the internet.

Philippines

Standard contraceptive pills are available over the counter in pharmacies. Most trans women here begin with these. Most other forms of HRT are readily available either with a prescription or on the on-line grey market. We will post links to proven suppliers, but HRT Philippines is at present the largest and most reliable.

Thailand

As above. Many HRT preparations which require a prescription in the Philippines can be freely be bought over the counter in pharmacies; just ask. Surgeons in Thailand are the best in the world and follow the WPATH guidelines. They are a good alternative to waiting for many years for NHS surgery, which in any case might well be withdrawn.

United States

In the US, depending on your city/state, you might be able to get HRT prescribed quickly (within a month) by a doctor, instead of having to self-medicate. Look for an informed consent clinic in your area.

If you can get HRT quickly via informed consent, we recommend doing that instead of self-medicating. Your insurance will cover any expenses, and if not, HRT is usually cheap enough without insurance, depending on income (it’s certainly cheaper than self-medicating, in a lot of cases).

We have a list of informed consent clinics here – if you know of any that are not listed there, let us know!

Suppliers

These companies are overseas (none of them are in the UK), but you can import HRT medications into the UK. It is legal to import them for your own personal use only.

InhousePharmacy.vu:

InhousePharmacy is well-known and commonly used by trans people when self-medicating. It has existed for a number of years, and the meds that they provide are the real thing.

The box that arrives will say “pharmaceuticals” on it. If you need to receive them secretly, without someone (e.g. parents) knowing, then you should use a PO box or a friends house, or anywhere where you can receive them safely.

Quality Health Inc:

This supplier ships to Portugal (Inhouse does not, last time we checked). For other people who can’t order from Inhouse, this company might also be usable.

The box that arrives will be blank, with no information on it from the outside. This is good if you need to receive it discreetly.

Regimens

Recommended pills (trans women):

  • Spiractin 100 (spironolactone)

  • progynova 2mg (estradiol valerate)

Spironolactone is a weak anti-androgen, and causes increased pottasium build-up in the body. We do not recommend it, unless you can’t get another anti-androgen that is better. We consider cyproterone acetate to be better, but individuals may respond differently. (Cyproterone is not available in the USA.)

Spironolactone doesn’t suppress T, but blocks some of its effects, so T may seem high on blood tests. Spironolactone also affects estradiol readings on blood tests (they’ll be higher than they actually are on the test).

Progesterone, the other female hormone, is not proven to increase feminization, and can lead to further negative side effects. There is some evidence that it might help promote breast tissue growth but on balance it is not necessary to take it.

Check whether you’re intersex FIRST

Do not self-medicate at all, if you are intersex. You will require special treatment, under supervision from a doctor.

This page has information about what intersex means: https://nonbinary.miraheze.org/wiki/Intersex

Endocrinology

The endocrine system is the collection of glands that produce hormones that regulate metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood, among other things.

If you can, go to an endocrinologist, aka an endo. This is recommended because an endo can tell whether HRT is safe for you to take, along with arranging and interpreting blood tests. In the UK, you can get a referral from a GP. If you’re already receiving treatment from a Gender Identity Clinic, they can also refer you to an endocrinologist.

In the UK, Dr. Leighton J Seal is one of the most well known endocrinologists specializing in transsexualism and  transgender, including intersex. However, you might also have luck with another endo if you don’t live near London (where Seal operates).

UK residents might be able to get help from CliniQ on things like blood tests and so on, to make sure that you’re safely taking HRT. They can offer advice. It’s a private clinic, but also part of NHS.

Blood Pressure and weight

Test your blood pressure. If you suffer from low blood pressure, you should not take spironolactone, for instance (use cyproterone acetate instead, or if you can’t get that, take finasteride and a higher estradiol dose). Similarly, if you have high blood pressure, you should get that sorted before starting HRT.

Feminising HRT might well cause your appetite and weight to increase, because most of the classic female ‘shape’ is actually made of fat. An increase in weight of 10-15% should be expected, so it’s better to be about right before you begin.

Side effects of various medications:

Watch out for seriousside-effcts e.g. blood clots, etc. If you get any, stop self-medication immediately and seek medical help. However these are rare. This paragraph is not meant to scare you away from taking HRT. You should take it, if you want to. But you are also taking your health into your own hands, so you need to be more aware of risks and act responsibly.

STOP SMOKING before you start HRT, including e-cigarettes and vaping. Smoking increases clotting risk.

Anti-Androgens

An anti-androgen either blocks testosterone or prevents t-receptors from responding to it. The most popular ones are spironolactone and cyproterone acetate. They have different side effects. You should research which one might suit you better. Often, this will come down to trying the preparation for a few weeks and seeing how it affects you. Do not be afraid to change if you have an uncomfortable reaction, like depression and so on. Inhouse and QHI both sell 100mg spironolactone pills and 50mg cyproterone acetate pills. (Cyproterone is not available in the USA.)

An alternative to spiro/cypro is flutamide or bicalutamide. Bicalutamide is usually taken at 50mg daily. Both affect certain liver enzymes which could be a problem; in extreme cases, jaundice and liver failure. They don’t suppress testosterone, but they block its effects, so free flowing testosterone in your body will not actually work. You should get regular blood tests if using this, but note, your t-levels will remain high as the drug doesn’t stop its production, just its effects.

Spironolactine reduces the amount of salt in your body, so you should take in more salt in your diet while using it. It also increases the amount of potassium in your body, so you should lower your potassium consumption in your diet. It is a diuretic, so be aware of this and maintain good hydration. Some spironolactone pills contain lactose, so if you are lactose intolerent you might have to avoid it.

Cyproterone acetate reduces iron and B12, so you should take supplements for those while using it.; any multivit will do. Avoid alcohol while taking cypro, because you can get massive hangovers with much smaller amounts. Cyproterone, on long term usage, depending on dosage, has been known to cause some depression symptoms.

Surgical testosterone blocking

The simplest way to prevent masculinisation is to surgically remove the testes. This is called ‘orchiectomy’ or ‘orchidectomy’ today, but in the past was called ‘castration’. It involves either the removal or destruction of the testicles.

Vaginoplasty or MtF Genital Reconstruction Surgery (GRS), almost always involves a bilateral orchiectomy, though a few surgeons leave one testicle inside the body. There are two problems with this: the first is that the testicle becomes a potential site for cancer and the second is that it will continue to produce testosterone. We do not recommend it.

If you’ve had  an orchiectomy then you do not need to take any anti-androgen, because your body no longer produces high amounts of testosterone. Orchiectomy, whether alone or as part of GRS, is completely effective at preventing masculinisation; however, ethical codes in the UK do not allow orchiectomy in adolescence, when it would be most effective.

Cis women also have testosterone, just in small amounts. Some women have to actually take testosterone (the same kind that trans men take), but in  small doses, to get their testosterone up to normal female ranges. After orchiectomy, some trans women actually have too low testosterone (this is why some surgeons leave one; but there are alternative approaches that are better.) This page documents some symptoms of low testosterone in women (applies to cis women and post-surgery trans women). Blood tests will show whether your levels are too low (most women are between 0.5 to 1.5 nmol/l testosterone levels).

Finasteride (Propecia)

Dihydrotestosterone (DHT) is what causes hair loss in men, or trans women who waited too long. Hair loss can be reversed, by taking Finasteride, which blocks it. You can get the 5mg finasteride tablets on-line (use a pill cutter to split them into 2.5mg pills, to be taken every 12 hours). Doctors usually prescribe between 1-6mg of finasteride. Finasteride can cause lost hair to grow back. It can be used as a mild anti-androgen for MtF transition.

Patches

NOTE: patches often contain ethinyl estradiol, which is not ideal. This is not bioidentical to real estradiol, but a synthesized version that is more potent. We recommend using the Estradot brand of patches (whether 25, 50 or 100mcg variant) because it uses the superior estradiol hemihydrate.

Most doctors start you off on 100mg spironolactone and 2mg or 4mg oral estradiol (or 1mg/2mg gels or 50mcg/100mcg patches) daily. Start on that first (low dose is recommended, when you first start HRT).

You might need a pill cutter, depending on what dose you take and how you spread it out into the day. Spread your spiro dose into 2 daily doses (every 12 hours), so for instance with 100mg daily spiro you’d split it into 50mg every 12 hours. Split the estradiol dose into 2 doses daily (gels) or 2-3 doses daily.

You should use spironolactone and estradiol, usually. If you can’t take spiro (e.g. don’t respond well to it, side effects, low blood pressure, etc) then you could try cypro instead (50mg daily – some trans women go up to 100 or 150mg). Most doctors would start you off on 50mg if using cyproterone acetate.

If you can’t or don’t want to take an anti-androgen (spiro, cypro, GnRH), you can take estradiol alone, which can block testosterone, but it means that you have to take it at a higher dose than usual.

GnRH

 GnRH anti-androgen injections are the most effective testosterone blockers. They are marketed as Leuprorelin, Lupron, Leuprolide and others. These stop the production of sex hormones altogether and for this reason have become popular.

However, some reports of serious complications or side-effects of GnRH  have been reported. These appear to be most severe in females.. For clarification, see the following:

Mayo Clinic (USA) https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/in-depth/pubertal-blockers/art-20459075

Gender Construction Kit https://genderkit.org.uk/article/gnrh-agonists/

Also please read these papers. These are scientific papers so if you are unused to reading these, just read the Abstracts.

https://www.thelancet.com/journals/landia/article/PIIS2213-8587(17)30099-2/fulltext (PDF download available via the link)

From the above:

Studies of BMD Bone Mass Density) in children with central precocious puberty treated with GnRH agonist therapy for at least 3 years did not suggest any bone density loss compared with typically developing children matched for chronological age and skeletal maturation. 33

Effect of Concurrent Gonadotropin-Releasing Hormone Agonist Treatment on Dose and Side Effects of Gender-Affirming Hormone Therapy in Adolescent Transgender Patients

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6818477/

Caveat

Other studies have confirmed that GnRH can have serious, lasting effects, especially in women, where it has been prescribed to induce tallness (!) Our opinion is that at the present state of knowledge it should never be prescribed in FtM transition and in MtF only used under the close supervision of a medical team. In other words, do NOT use GnRH in self-medication, ever. Other anti-androgens work well enough, in conjunction with oestrogen, to make its use unnecessary.

The sex hormones are implicated in developing bone mass, so it is our opinion that GnRH, and for that matter other anti-androgens should not be used for longer periods, certainly in adolescents, without also providing appropriate sex hormone replacement therapy.

This challenges one of the conventional wisdoms which suggests puberty blockers, then HRT then, if necessary, surgery. We now consider it better to begin anti-androgens and oestrogen HRT at the same time, around the age of 12-13 in confirmed cases of male Sexual Inversion.

Oestrogen alone can also block testosterone. In the old days, trans women were given only oestrogen, in high doses, because anti-androgens were not available. However, very high doses are required because testosterone is much stronger than oestrogen. The combination of anti-androgen (or orchiectomy) and oestrogen is both safer and more effective.

Patches

If you don’t want to take oral estradiol, then you can use oestrogen patches. We recommend Estradot 100. This is 100mcg of estradiol hemihydrate, equivalent to about 2.5mg oral estradiol daily. You wear the patch for 3 days (you can still shower, swim, etc) and replace it after 3 days, wearing each patch for 3 days. You might get marks around the patch, on your skin, but this is just residue from the adhesive. You can remove it. Wear it on your lower abdomen, around your hips on either side, left or right.

Testing Regimen

Two months after you start HRT, get estradiol and testosterone levels checked in a new blood test. Female range is about 0.4 to 1.5nmol/l testosterone, and 400-500 pmol/l estradiol (some trans women go between 500-600). You will start developing breasts and your face will transform, as will the rest of your body. If your T is too high, *and* your estradiol is too low, try increasing your estradiol dose a bit – e.g. from 4mg to 6mg, and check levels again in 2 months. Note that the extra estradiol will also lower T a bit more. If T is still a bit high on the next blood test, try increasing your anti-androgen dose.

If you’re taking HRT while getting blood tests, then before each blood test make sure that you take your dose 1 hour before, assuming that this is 12 hours after your last dose, so that you know roughly what your peak levels are.

This website also has some useful information about HRT for trans women. NOTE: some of the information there is highly experimental.

Blood tests

It is advisable to get blood tests before you start HRT. However, this is not always possible, because GPs may object, if they think you are indulging in self-medication, or may not want to spend their resources in this way.  If you are under 16 and your doctor insists on telling your parents of your request but you do not want them to know, then your rights are protected under the Gillick-Fraser Guidelines; you may have to remind him or her of this.  While blood testing is valuable and recommended, most of the world’s trans women self-medicate without it and you should not let your GP impede you.

 

If it is possible to do so, go to your GP and ask for these tests:

  • urea and electrolytes

  • bone profile

  • thyroid function

  • C reactive protein

  • ferritin

  • full blood count

  • baseline full blood tests

  • random glucose

  • FSH

  • liver function

  • estradiol

  • testosterone

  • rheumatoid factor

  • SHBG

  • HDL cholesterol

  • TFT1: suspected thyroid disease

  • uric acid

  • lipids

  • LH

  • prolactin

  • cortisol

  • dihydrotestosterone (DHT)

book an appointment with your GP, and ask for the authorisation form, then find the hospital in your area that holds the blood samples, and go there to get your blood taken. They’ll send the results to your GP usually a week later, and you can go to collect them. If your GP refuses to authorise a blood test, try another GP. Some GPs are unhelpful and many are ill-informed, and once again, make it clear, if there are problems, that you do not consent to your parents being informed of your request, under Gillick-Fraser.

Every 3 months afterwards, get these tested:

  • liver function

  • testosterone

  • estradiol

  • potassium (if taking spironolactone)

  • B12 (if taking cyproterone acetate)

  • Iron (if taking cyproterone acetate)

Trans men (FtM)

Trans men, that is, females undergoing FtM transition,  take testosterone in order to transform their nody morphology. This is a controlled substance in the UK, and not legal to purchase without a prescription, unlike male-to-female HRT. Despite this, it is readily available on the black market. However, by purchasing it you would be committing a crime and might gain a criminal record. Further, we do not believe that it is appropriate for FtMs to self-medicate with testosterone, for the reasons given above. Any transition for FtM, other than purely social (ie, cross-dressing) should be supported by a full psychological evaluation and medical supervision, under WPATH guidelines.

We deeply sympathise with those female Sexual Inverts who feel discriminated against because of this but the fact is that the current system has been abused by individuals who do not have Homosexual Gender Dysphoria, who have lied and misrepresented themselves to get treatment and then have claimed that the fault, for the consequent ruination of their bodies, lies with the institutions which agreed to help them. This has now proceeded to court cases and these spurious allegations will certainly be, indeed already are being, used to attempt to limit the availability of service to genuine HSTS. I am afraid you only have your sisters to blame.

DISCLAIMER

The above information is advisory only. We are not responsible for any harm that you may bring upon yourself by following it. Self-medication is usually safe and most trans women do it, at least in their early transition. However, some people can have negative reactions. Proceed with care and do not self-medicate at all if you have other health issues.

You are responsible for your own health, and we take ZERO responsibility if you don’t do your research properly before self-medicating. We try to provide accurate information on this page, but we cannot guarantee it. You should seek proper medical advice. Self-medication is a last resort. It is made inevitable for some by under-provision of services, ill-informed gatekeeping doctors, long waiting times to receive hormones from your doctor or absurdly long waiting times to even access a Gender Clinic appointment.

Self-medication is always somewhat risky, but dysphoria is also risky and delaying HRT can prevent individuals from living their loves as they desire. It can even be deadly for some. Most distressingly is that a small group of transphobes are attempting to prevent any transition treatment at all, because it does not accord with their ideology. We are trying to mitigate the effects of this.

In the longer term, if the transphobes have their way, the purchase of feminising HRT may be made illegal in the UK, meaning even more risks for the individual whose only remaining option is self-medication. If this occurs, then orchiectomy — which was once widely used — may become popular again.

External links